Monday, March 22, 2010

Psychologists Prescribing: The Best Thing That Can Happen to Psychiatry

First, I apologize to readers of my blog for the paucity of posts lately. The reason has nothing to do with my health (I had a mitral valve repair surgery at the end of March and have recovered uneventfully). I’ve been too busy with a bunch of things, all of which are coming to fruition this May. These includes a book called Unhinged: The Trouble with Psychiatry; an article to be published in the New York Times Magazine; launching a new newsletter called The Carlat Child Psychiatry Report, to be edited by Dr. Caroline Fisher; and new blog columns for both Psychiatric Times and Psychology Today.

So I won’t be able to keep up the twice weekly pace that I think is truly minimal for a good blog, but I’ll do the best I can.

Today I want to touch on what is probably the hottest topic in psychiatry: whether psychologists should obtain prescription privileges. This is topical because Oregon just overwhelmingly passed a law authorizing prescriptive privileges for psychologists, although it is unclear whether the governor will sign the bill.

I endorse psychologists prescribing, and here’s why: it would be the single best thing that could happen to psychiatry. Yes, I know it sounds ridiculous, but here’s my reasoning. Psychiatry has boxed itself into a tiny corner of medicine called “psychopharmacology.” It’s a silly way to practice our craft, because the essence of what we do is to understand the mind and to help people live better lives. Drugs are effective but only one of the tools available to us, and we have largely ceded psychotherapy to psychologists and social workers. The result is a fragmentation of care. You see your “p-doc” for your meds, and you see your therapist for your mind. Each professional is far too busy to communicate with the other.

While there are plenty of patients out there who do so well on meds that they don’t need therapy, the majority of patients do best with both meds and therapy. But psychiatrists rarely provide the full package of treatment, because we are trapped in a system of incentives that discourage integrative care. Insurance companies pay more for med visits. Drug companies throw the full force of their marketing machinery into pushing medications. The top psychiatrists find that the road to academic glory lies in psychopharm research. And our anachronistic training system, which requires that psychiatrists attend medical school, selects for practitioners who see people in terms of discrete diagnoses, and who are rarely psychologically minded.

Enter psychologist prescribers. These are professionals who went into their field because they are fascinated by the human mind. From early in their training, they learn about psychiatric diagnosis, psychological testing, psychotherapy, interpreting behavioral science research, neuropsychology, etc…. They don’t go to medical school, so they learn nothing about such crucial psychiatric topics (being sarcastic here) as gross anatomy, histology, pathology, or the physical exam, nor do they have clinical rotations that psychiatrists draw upon daily, such as Ob/Gyn, surgery, internal medicine, radiology, and others. Thus, psychologists don’t learn how to deliver a baby or how to tie a surgical knot, but they do learn how to get at the root of anxiety and how to keep patients coming back for treatment.

Psychologists first obtained prescriptive privileges in the military through the Department of Defense demonstration project, and since then have been awarded privileges in both New Mexico (2002) and Louisiana (2004). The lengths of the training programs vary, though they are typically two year programs incorporating both didactics and a clinical practicum. Many have charged that these two year mini-programs cannot possible produce safe prescribers. But the evidence contradicts this position. There have been no adverse events reported in any of the programs operating thus far.

As the safety data gradually accrues, I predict that psychologists will attain prescriptive privileges in most states over the next 10 to 20 years. We saw the same pattern in the 1970s with nurse practitioners—psychiatrists and other physicians engaged in bitter turf wars initially, arguing that they didn’t have enough training, but large scale health services research studies eventually demonstrated that NPs operated competently and safely, and now they are accepted as independent practitioners in most states. As it turned out, there is so much business to go around that psychiatric nurse clinicians have not eaten into psychiatrist’s practices or incomes. On the contrary, since NP’s must receive regular supervision, many psychiatrists have developed side gigs supervising nurses, charging $200 to $300/hour—more than you can make seeing patients.

According to some psychologists I have spoken with, the early experience in New Mexico and Louisiana is that psychiatrists and medical psychologists (that’s what they are termed in Louisiana) are accommodating to one another and that psychiatrists are not losing business. But as more and more states approve prescribing psychologists, this will probably change. I predict that patients will vote with their feet and preferentially see prescribing psychologists once they realize that such practitioners provide one-stop shopping—meds and therapy combined.

And herein lies the great opportunity for psychiatry. As psychologists gradually become serious competitors for our patients, we will have to re-evaluate how we practice and how we are trained. We will have to take a close look at our catastrophically inefficient medical school-based curriculum. We will have to decide which medical courses are truly necessary and which are not. I suggest that the process begin with a work group created jointly by the American Psychiatric Association and the American Psychological Association. Yes, let’s get psychiatrists and psychologists in the same room, and create an ideal curriculum for integrative psychiatric practitioners. Let’s face it, going to 5 to 7 years of psychology graduate school, then capping it with 2 years of psychopharmacology is not an efficient use of training resources. It’s almost as inefficient as going to four years of medical school, one year of medical internship, then three years of psych residency.

There must be a middle path—perhaps a five year program that would interweave coursework in physiology, pharmacology, and psychology from day one. The specifics would require much thought and discussion, and would best be done by reverse engineering. Start with the ideal psychiatric practitioner, list the core competencies such a person requires, and then figure out the very best way to teach those competencies.

On the other hand, organized psychiatry can continue on its current path, which involves throwing millions of dollars into lobbying efforts to fight psychologists. The money is being wasted, I can guarantee that. At the end of the day, we will be on the sidelines as patients flock to prescribing psychologists and our professional sphere constricts further and further into a narrowly defined neuropsychiatry role. We can do much, much better than that.

111 comments:

Dr. Carlat, first of all, I'm glad you're ok after your surgery. Most of what you say here is eminently reasonable. You start to lose me in the last 3 paragraphs, though, with the idea that there should be a different integrated training program for mental health professionals, citing the vastly inefficient medical school system.

Well, to your modest proposal, I'd like to add my own. Since most doctors don't use most of what they learn in med school, why don't we make training more efficient by establishing Doctor of Ophthomology programs, so ophthomologists don't have to go through so much schooling just to focus on the eye. And Doctor of Dermatology schools, for the same reason. Heck, Doctor of Surgery would make sense too, since surgeons clearly don't bother messing with insulin and other "medicine" things. And why make future pediatricians learn about anyone over the age of 21? They'll never see dementia or alcoholic cirrhosis. And why have MD/PhD programs when most of those folks just want to do research?

I know you would probably say that the problem is that the medical model doesn't apply well to mental illness, and you're probably right. Yet many patients and practitioners see value in that model, and it helps us organize the complexity that is the human mind. And right now, the advantage of psychiatrists is exactly that we can do both psychopharm and therapy. Good residency training programs teach both those things. So why not recommend improvements in residency training, instead of some quixotic idea that can never happen?

--There are indeed various scope of practice skirmishes occurring all over medicine. Optomotrists vs. ophthomologists, podiatrists vs. orthopedists, midwives vs. Ob/Gyns, and the list goes on. In each case an allied profession has taken a chunk of the MD's practice, in each case there was the usual round of arguments about safety issues, training, competence, and in each case the non-MD practitioners pretty much got what they wanted because their positions made sense and enhanced treatment access, reducing cost. For me, the key lesson in all these cases is that it's possible to take a measured look at what skills a given professional actually needs, and then create a more efficient training program to produce such a professional.

--To your point on improving psychiatry--sure I'm in favor of that. In fact for years the Residency Review Committee has required a minimal level of therapy training but that has done nothing to stem the tide of psychiatrists spurning therapy for the more lucrative psychopharm.

--Call it pie-in-the-sky, or a pipe dream, or a utopian vision, but people create institutions and people can change them radically if they decide to do so.

You had me there with you in the beginning, and then...I disagree with you so much I have a hard time putting it into words. Medical education is not about tying a knot. It's about seeing people in every state imaginable and taking responsibility for their lives. It's about learning how to think in a certain way, call it the medical model if you will, call it a form of logic or learning what's important and what's not, what makes sense and what doesn't. It's also about you, a psychiatrist, having had the experience of rushing to a code at 3AM when you were in training, or a cardiologist sitting at a pts bedside and talking to them gently about their options.

Our profession has been demonised and its stature attacked from all sides. Medical thinking especially in psychiatry is not valued at all. And medical does NOT mean psychopharmacological. Go to a psychoanalytic meeting (a dying breed) and you'll see that most of the attendees are MDs. OTOH, if you were to sit in a public clinic, you'd have the experience of most patients coming in proclaiming they've being diagnosed as 'Bipolar' - by their therapist, who also told them you'll give them 'meds'. The lesser the training, the more prone these therapists are to the distorted reductionist psychiatric 'medical model'! Go figure.

Furthermore, the presence of NPs who do not have one smidgen of our training, or even worse - case managers who function as the mental health consultants in many hospitals, has made it harder and harder for psychiatrists to find work, let alone any kind of meaningful work. These others are cheaper, and that's all that matters to admin. Think about this - your relative is in an ER and needs a psychiatric evaluation. Do you want it done by a case manager? That is the state of the art in many places. When you move away from academic programs, MDs are less than nothing.

The use of these non- MDs as 'MD equivalent' belays both a complete lack of understanding of what we do and an utter lack of respect towards our cognitive faculties. We are nothing more than scribes to the system.

BTW, last I heard, when it comes to therapy, psychologists are the most un-psychodynamic creatures out there. Also, their education focuses a lot on research. Does any of that make them more understanding of people than an MD?

We have enough entities attacking us from all sides, no need to join forces with them.

Hey FunPsych: Good residency training programs teach both psychopharm and psychotherapy? Maybe. But you can count on ONE hand the number of psychiatry residency programs that are serious about teaching psychotherapy. Face it: The only psychiatrists who are proficient at therapy are over 60 years old now.

You bring up so many interesting points—but first let me clarify that I do not intent to attack my own profession, but rather to reform and improve it. The scientologists and their ilk, who refuse to believe the evidence that most psychiatric medications work very well, are the attackers.

1. I agree with you that some of the key benefits of my medical training were the intangibles. The feeling that I, and only I, was responsible for the welfare of a patient. The drama of staying up all night to keep a patient alive in the ICU. The understanding, felt in my bones, that sometimes it truly is a matter of life and death. However, do you really think one has to go through four years of medical school just to learn these lessons? My experiences in psychiatric inpatient units and covering the psychiatric emergency room were very dramatic, taught me painful and exhausting lessons about responsibility, and showed me that death is only a noose away from some patients. These were experiences that do not require four years of medical training. They require training in psychiatric diagnosis, in biochemistry and pharmacology, in alliance building and psychotherapy. Most of what I learned in medical school was not relevant to these skills.

2. You mention “medical thinking,” and by that I think you mean a careful deductive thought process that incorporates all the data before reaching a diagnostic conclusion. This is a skill I learned primarily after residency, and I am still learning it. It requires seeing many patients, diagnosing them, and then following them to see whether your diagnosis was accurate, and whether it led to a treatment that was effective. Medical school is not uniquely required to teach a logical diagnostic thought process.

3. When you discuss NPs and case managers, you demean them unfairly. In any profession there will be a spectrum of skills and talents. I’m sure you can name some psychiatrist colleagues who practice checklist psychiatry and dole out medications after 10 minute visits. There are sloppy psychiatrists, case managers, and NPs, but that doesn’t reflect on these professions or the training as a whole.

You phrased better than I did the concept of 'medical thinking' - but I believe this IS something you learn over the course of medical school.

As for demeaning other professions - I certainly did not mean to. And I could name many names of terrible psychiatrists, who have the empathy of a tree and the logical capacity of a brain dead frog. However, as much as I might like a non-M.D. mental health professional personally - I must say what is not PC. It's not a matter of "there are good and bad people in every profession". All the 'others', each profession having of course a very different set of skills, are lesser than a psychiatrist in OUR field. They could be much nicer people (social workers often are), I might be much more likely to befriend an art therapist or a nurse than a psychiatrist (this in fact is the truth), but we have let them encroach on our professional territory and we and our patients suffer as a result.

I don't know the first thing about handling an ICU patient - the nurse there is infinitely more knowledgable than I am. But the ICU doc is a different matter entirely. Again, do you want your relative in the ICU treated by nurses (i.e. prescribing the treatment, not just giving it) or do you want a physician to be in charge? The best witnesses to the difference between nursing and medical education are nurses who changed their career path and went to medical school.

Nurses, btw, including nurse practitioners, are very protective of their own and often have no compunctions in stating they are equal to physicians. Nurse practitioners in my town refer to OTHER nurse practitioners when they don't know what to do. And here they practice entirely independently. We, OTOH, have been too far too meek and polite, ceding our professional status without a fight. Go to allnurses.com, read a bit...not pleasant and certainly not PC.

I am sure you want a surgeon operating on you (glad to hear you're doing well, btw!), and not a nurse who took a part time, one day a week, 2 yr college course in surgery. Our own skills are less tangible - but are they really less important and unique than those of a surgeon? If not, can we truly be replaced by a different profession? If the answer is yes, then are you ready for non physicians performing surgery?

Actually, I think my Seroquel XR and Abilify sales reps would make great prescribers, too, since they have such a terrific handle on how effective their meds are, the proper indications for these meds, and the correct dosing!

Heck, I sometimes wonder why I spent so many years in medical school when they seem to know precisely what will work and for whom.

To answer your question—I insisted on a medical school-trained surgeon for my operation. Why? Because surgeons spend their time cutting open bodies and repairing organs. This job description requires exactly the training which medical school provides: knowledge of physiology, anatomy, and physical diagnosis.

Psychiatrists, on the other hand, spend their time understanding emotions, thoughts, and behaviors, and then figuring out just the right combination of medication and psychotherapeutic treatments for a given problem. I submit that medical school is not the right training for that job description, and that we can create something much better.

I do not agree with you Dr. Carlat. The point and purpose of going to medical school for me was to have a comprehensive understanding of the entire human body and its physiology and pathophysiology. In this way, I could address my patients in a more holistic fashion, even though I am 'just a psychiatrist.' I do my patients a service by being able to understand and explain to them muscle physiology, inflammation and oxidative stress, nutrition and enzymatic processes and cofactors, as well as the miniscule amount that modern medicine understands about neurophysiology (in comparison to other organ systems). Then I can put all these together and treat my patients as their physician, not just renew their meds. I was fortunate enough to receive training in psychotherapies so that I do periodically communicate with the therapist on cases to coordinate treatment plans. As we learn more and more about the workings of the human brain, the ability to integrate this with the rest of our knowledge of medicine is key and is what will make a difference for our patients. It seems you devalue your role as a psychiatrist by believing that others without your medical training can do a 'good-enough' job. Shame on you.

Just to add this last comment, I think surgeons would say that their most important task is thinking, not cutting. And more important than cutting is knowing when, why and when not to operate, and what to do when things go wrong. I don't think there are shortcuts to that in surgery. Nor in piloting planes - see Sully. Nor in psychiatry. I also think there's nothing left to fight for - the war has already ended, and we've lost.

Well, Danny, you've done it again: taken a controversial position and stated it firmly and clearly.

And now, of course, being human, we readers/responders will proceed to go limbic in one direction or another. It would be nice if while we're doing it, we could listen for our own pre-existing biases and blind spots.

Of course, that's utopian. In any case, thanks for speaking out as you've done. I'm working with one of those Oregon psychologists right now, trying to help design the post-PhD post-Master's training program. You're right, it's coming, so let's figure out how to influence it for the best. If it weren't coming, Psychiatry would bear significant responsibility for continuing the appalling lack of access to mental health care that we have out here in the West, given the way our professional organizations opposed the Oregon bill. Rather like politics, it was: you dont' have to have a solution, you just have to keep preventing one you don't like.

Ironically, as you point out, we'll be influenced for the best ourselves -- in the long run, at least. There, maybe some of the limbic heat will fall on me now. Have at it, y'all. Care to examine whence it comes?

You're getting wrapped around the axle on an off-ramp apart from Dr. Carlat's observations and proposition.

His focal point is not the differential capabilities of various practitioners who provide mental health services. It's that the normative model for psychiatric practice is broken. And he's proposing a solution for it.

Re: FunPysch "...your modest proposal..." Actually, Dr. Carlat's proposal is pretty radical. Because it shakes the cage of the entrenched psychiatric infrastructure. And unfortunately, its radical degree probably makes his proposition of a mixed academic model administratively infeasible. The psychiatric gods on Olympus would never buy into “diluting” medical training. Look at autumns_leaf. He/she is already having a conniption. Imagine Alan Schatzberg hurling lightning bolts of opprobrium from his finger tips.

Here’s another wrench in the machinery. Psychotropic drugs may have more circumscribed benefits than originally envisioned. But can’t the same thing be said for psychotherapy? I.e., aren’t there patients in psychotherapy for years that effectively become cash cows for their therapists who hold whatever degree? As a practitioner, what fun is that?

Maybe that’s where unsettled practicing psychiatrists get directionally stuck. They know that the drug-centric therapeutic model does not offer a holistic solution, but psychotherapy may be just moving neurotic food around the plate from their PoV. So the need then is a rigorous, but compact training platform of non-drug therapies that map to psychiatrist sensibilities.

But administrative constraints mean that the training probably has to be delivered in the context of the existing academic models. Seminars at conventions or short courses on non-drug interventions are insufficient in catalyzing skill development.

I don't like biological psychiatry and I think that far too many pills are prescribed already.

I fear that If psychologists can prescribe too, then even more pills will be handed out. And what is to stop psychologist from reducing visits to 20 minute med checks so they can make a higher profit than they would for 50 minutes of psychotherapy?

My pdoc works at a hospital and she prescribes drugs and seems pretty clueless when it comes to the mind. I'd be miserable if I did not have a therapist. I see my pdoc as seldom as possible because it is just too upsetting to be in a medical enviroment, where I know they can drag me off and lock me up against my will at any time. (They locked me up from age 16-18. So going to the hospital to see her gives me all kinds of flashbacks.)

So if I could see a psychologist for meds I guess it would be better but still I don't want meds mixed with therapy because I think that biological psychiatry is a load of B.S. and every time my therapist mentions dopamine or genetics, in my mind, it discredits everything else she says. And that makes therapy ineffective.

On the other hand if psychologists could compete with psychiatrists maybe more psychiatrists would be forced to take Medicare. As it is there his not a single psychiatrist in my entire county who will take Medicare. I had to see a P.A. until I was finally able to find a pdoc in a neighboring county.

Seeing a P.A. and not seeing a pdoc cost me a denial when it came time to review my disability. But, I appealed and won after I found a pdoc in the next county over.

If Psychologist could prescribe mindbenders, I think that Pdocs would still be needed for medical documentation of a disability. But that is basically all I see my pdoc for now anyway. Then I go see my therapist to recover from seeing my pdoc.

So from a practical point of view, what is an alternative solution if Dr. Carlat’s mixed model proposal is taken off the table and CME type stuff is trivial? How about this? Maybe an adaptation of Dr. Martin Seligman’s Positive Psychology program at Penn.

Dr. Seligman was smart. He was unhappy with normative psychology’s bent, so he carved out a psychology specialty within his own domain. His program offers a Master in Positive Psychology that is a one year curriculum. Use that as a training template and offer a one year Master in Applied Psychology program available to psychiatrists. They could continue clinical work on the side. Incorporate the curriculum into the residency program for incoming psychiatrists.

Utilize the elements of “whatever works” from conventional and positive psychology in the training, including CBT, meditation, cognitive hypnosis and self hypnosis training, Heart Rate Variability training, explicit emphasis on diet and exercise management, utilization of computer assisted therapy, etc. I know you guys already wave at that stuff. But immersive training in those techniques would provide the confidence to actually employ them. Perhaps even employ them first before drugs.

And maybe psychiatry (and psychology) could take a lesson from orthopedics. These days, it’s get the patient into rehab and up and around right way, right? Similarly, rather than sitting in a conversational sandbox for months or years with a patient, holistically trained psychiatrists could catalyze improvements in cognitive behavior out of the box. With or without medication. That would appeal to their scientific mindset that explicitly maps a therapy to a specific (near-term) outcome.

I admit I’m not inside baseball like you guys. But does any of this make sense?

P.S. One potential unintended consequence of the “medical psychologist” construct is that those practitioners would devolve their treatment model to the 15 minute med-check paradigm for the same reasons that psychiatrists already have. Human nature being what it is, the phenomenon can probably only be precluded by professional organizations defining a holistic standard of care that proscribes it.

Dr. Carlat, since you don't like it when your profession is stereotyped as big bad evil psychiatry, I would greatly appreciate if you would stop referring to people who doubt the effectiveness of psych meds as scientologists and their ilk. That is demeaning and frankly, I am surprised that someone like you would resort to that type of argument. I thought you had more class than that.

Anyway, I keep asking for evidence on this blog that antidepressants are effective on this blog but I keep getting ignored. As far as I know, there is no 5 year study that proves they work well. Sorry, basing something on a 6 to 8 week study doesn't cut it. And I would say the same thing for non psych meds.

As for psychologists prescribing meds, my initial reaction is h-ll no. If many doctors are clueless about med interactions (it isn't just psychiatrists who are guilty), why the heck is a psychologist going to do any better?

It isn't just necessary to understand psych meds as the psychologist needs to understand the interactions with regular meds.

Also, is he/she going to be able to understand when someone is having serotonin syndrome or neuroleptic malignant syndrome?

First, I'd like to express my relief that my Tufts colleague, Danny Carlat, is recovering well after his surgery--good for you, Danny!

I also want to congratulate Dr. Carlat on what is surely one of the most effective satirical sketches since Jonathan Swift's famous (or infamous) "Modest Proposal", in which Swift appears to suggest that the impoverished Irish might ease their economic troubles by selling their children as food!

Dr. Carlat here achieves the same satirical effect by suggesting thatpsychologists ought to be granted what are often euphemistically called, "prescribing privileges"; i.e., practicing medicine without a medical license.

In a piece I wrote almost 20 years ago, I was, alas, unable to achieve Dr. Carlat's trenchant humor, as I tried to show that the "deep structure" of psychology differs radically from that of psychiatry and general medicine. [Pies R: The "deep structure" of clinical medicine and prescribing privileges for psychologists. J Clin Psychiatry 52:4-8, 1991].

Of course, anyone who has read Dr. Carlat's excellent texts on drug-drug interactions in psychiatry (e.g., "When Molecules Collide: Drug Metabolism in Psychiatry", 2005) will know that he, more than most, is acutely aware of the dangers that face patients taking psychotropic medications along with medications for "general medical" conditions--not to mention patients with impaired renal or hepatic function; co-morbid medical conditions; or those using over-the-counter agents, such as St. John's Wort.

No doubt Dr. Carlat and I would both go into apoplectic fits if we knew of a patient taking multiple medications from her internist; demonstrating impaired hepatic function; possessing an unusual genotype for drugs metabolized by the cytochrome 2D6 system; and coping with concurrent diabetes, who was being prescribed psychotropics solely by a "medical psychologist."

Both Dr. Carlat and I would probably agree that when, at 3 in the morning, the patient has an unexpected side effect--such as palpitations--that the "medical psychologist" is not going to want to take the patient's phone call--or indeed, to assume medico-legal responsibility for the unexpected complication.

But then, Dr. Carlat and I would probably agree that many psychiatrists would also be uncomfortable dealing with such a "medical" problem; and that many might not even be aware of the relevant drug-drug interactions or medical conditions that might explain the patient's problem. Many psychiatrists have indeed allowed their medical skills to wither on the vine, and have failed to keep up with the latest information on pharmacodynamics, pharmaco-kinetics, drug-drug interactions, etc.

And so it is clear to me that Dr. Carlat's biting satire is a clarion call to our fellow psychiatrists--a call both to enhance and strengthen our medical skills, and also to retain (and regain) our broader, humanistic orientation to the "whole person."

I believe Dr. Carlat's lampooning of "medical psychologists" is indeed a wake-up call to psychiatrists: a call to master physiology, biochemistry, internal medicine, pharmacology and, yes, psychotherapy, too--and thereby to become the kind of holistic physicians that we were meant to be.

I honstly do not know what to say to you, sir. It must be nice to have other career options to fall back on to sell out our profession per the tone of this post. Per what other comments above have said, let's just dumb down psychiatry and go with what a patient wrote to you about a year ago: let's make psychotropics over the counter meds!!!

What, you see the writing on the wall per what health care reform legislation will do to psychiatry? Every one can be a prescriber, as life is now "better living through chemistry."

Wow, to read how more and more colleagues are selling out! I am sincerely glad to hear you are ok per your surgical intervention. I will be frank and say this was not the first post I wanted to read upon your return.

Good luck in future endeavors. Another blog I can unfortunately say goodbye to.

I really hope you'll post this, as it is about being frank and direct.

This has been an interesting process to "process." A reasonable post with suggestions towards the transformation of a system and the requisite system "gatekeepers" angrily denouncing the challenge to the status quo. It has the flavor of our recent healthcare debate.

As for the underlying issue, as a primary care psychologist, a new breed of fully integrated PCP-helpers, the comments by psychiatrists on this blog are endemic to the cause of the mental health access problem in our nation. 50% of Americans with mental health concerns go untreated each year and most that do get treatment are actually getting it in primary care (hence my job). Clearly the status quo cannot persist.

Psychologist prescribers are one solution to this problem. Primary care psychologists are another. But we also need psychiatrists willing to change the way they work - for example, working as primary care as consultants. So there is room for transformation in this specialty, if psychiatrists would be willing to loosen their grip on the field.

Finally, I really appreciate the honesty of the post in acknowledging that much (not all) of psychiatry could be managed with more specific, targeted training. I have worked in primary care for close to 10 years and consider myself as fairly well-versed in medication management. I know this statement will cause a furor among some here, but much of it is not rocket science. There are decent algorithms for treatment out there and the bulk of common psychiatric medicines do not require the hyper-management of say, diabetes meds. This can be taught in less than 7 years.

Don't get me wrong. I do not mean to demean anyone. In fact, much of what psychologists do is not all that complex either (and SWs, and other master's level folks do just as good a job at it as we do). Let's simply be honest, step outside of our contexts to see the larger, national picture and embrace a future that is inevitable. Thanks for an excellent post.

I recently found your blog and was excited for the interesting and fresh view on topics. However, this is leaping too far into the perfect world of the Ivory tower.

Would you are suggesting is the dumbing down of psychiatry. If you are going this far then you may as well follow the slippery slope to legalizing all medications as over the counter and permiting anyone to prescribe. Let the patient choose with their pocket books who they trust their health with.

We both know who will recieve the most dollar "votes" of confidence. I function under the simple rule of treating patients as well as I would treat my own family. I wouldn't recommend my own family to a pscyh PA, psych NP, or prescribing psychologist.

They actually had the training program you are talking about in California in the '70's. I believe it was a combined effort of Langley Porter and Berkely (although I may be wrong on the latter). It was a six year program with four years of academic training and two of residency and at the end students were awareded a Doctor of Mental Health. For a few years the graduates were allowed to prescribe at state facilities, but eventually they lost the privilege. Most ended up as licensed psychologists.

This is an interesting debate. The over educated old guard hanging onto the last scrapes of imagined power with little more than presumptive claims of authority to bolster their argument and from behind an increasingly aggressive group of none-physicians desperate to pass out pills that really don't work well for most better than sugar pills and may actually be bad for many. How sad for psychologists but it speaks volumes about the desperation of all groups in this field to get a more comfortable seat on a burning plane that's going down. Dr Carlat is of course correct in that almost all of a medical eduction is a waste for psychiatrists.Mine hardly ever is of value and I work in a med-surg hospital doing consults.Of course there are exceptions but they have nothing to do with giving people Seroquel but rather just telling the attending a woman has aseptic meningitis and is not insane.I supervise 3 APRN's almost all who are better than any psychiatrist I have ever worked with when it comes to making pts feel better. God,people with MD's and psych training may be some of the worst folks at talking to those with emotional problems that I have ever seen. On top of this despite not one shred of evidence, both groups claim that lots more training improves their psychotherapy outcomes. Psychiatry is and always will be odd man out in medicine as its very existence is based on myth and an absence of real knowledge. We need neurologists/primary care Drs who are attentive to the behavioral nuances of neurological/medical disease.After it is clear that pts are not really ill lots of people can do the same thing psychiatrists are claiming only they can do really well.I don't think many psychiatrists are very good at much of this as few actually really spend time with sick people after training is over. Regardless of any of this,people who have sunk so much time and money getting to a high position in life are not likely to admit they are not any better at it than a less educated person or move over so that another group can have a seat at the table to have a piece of the shrinking pie. I think someones feelings are going to get hurt in the end of all this.

One of the things often missing in these debates is the perspective of patients. I am a licensed clinical psychologist working in a primary care clinic in a medically underserved urban community. In a recent survey of attitudes about medication tx for psychological/psychiatric problems, our patients overwhelmingly reported low interest in the professional affiliation/training of the prescribing practitioner. Instead, they wanted someone who worked closely with and was in the same practice as their primary care provider, who really listened to, understood and could help them with their problem. In other words, they cared about relationships and results, not pedigree. If we can effectively treat and maximize long term, holistic relationships with patients through changes in the training of psychologists & psychiatrists and in prescription privileges policies through some of the means you suggest, I'm for it.

As a psych NP student I mentally rebelled against taking a required physical assessment course. I'd never seen a psychiatrist touch a patient and in every place I've worked FP physicians performed the physicals. I had no problem with learning differential diagnosis, however I hope to never have to do another pelvic, especially before group therapy.

I was already an advanced practice psych nurse before going to NP school, but I'm scared about prescribing and I review Stahl's (and other books) continually. I realize my place and always want MD backup. What kind of training physicians go through is not for me to say, but I really like this field...giving drugs hypothetically thought to work on certain symptoms hypothetically thought to be caused in certain areas of the brain. What an art!

I value the internal medicine part of my residency and my medical school experiences in other specialties for the intellectual stimulation, the knowledge of what is an emergency and what is not.

But my patients appreciate my medical training when I diagnose that patient referred for an agitated depression as having an MI (true!), and countless depressed patients as being hypothyroid, and so on and so on.

I've thought about this some more after reading what autumn_leafs and Dr. Carlat said in the comments, and here's what I think: Perhaps psychiatrists can do without medical school, but I don't think medical training can do without psychiatrists. Let's face it, medical schools are not good at teaching future doctors to be empathic.

In my own experience, many of my med school friends became quite jaded by the drug-abusing, homeless, somatizing, demanding, etc. patients that they saw on their clinical rotations. The psychiatry rotation is one of the few that helps med students think about those patients and how they are suffering in their own ways. It helps de-stigmatize mental illness and promote psychological-mindedness amongst future doctors. It emphasizes the treatment of people and not just diseases.

Should medical schools lose psychiatry, the entire medical profession would lose an important humanizing influence.

I am suspicious about who is really behind this push to open up prescribing privileges. After all, it doesn't seem to be that much in the patient's interest to have more access to pills which are little better than placebos. It doesn't really seem to be in the long-term interests of psychologists as they will simply end up like psychiatrists, relegated to prescribers for the most part. Furthermore where did all the money to lobbey for these laws come from? I didn't think the psychological societies were that awash in cash.

So my hypothesis is that the real sponsors of this legislation are the pharmaceutical companies. They definitely will benefit from opening up prescribing privileges. And there will be a host of new clinicians for the drug reps to schmooze, especially as MD's have cooled toward them.

WOW. Goody. Great subject.Lots of meat and potatoes to dig into.I too, am happy that your surgery went well (even though I don't "know" you very well at all..)I was trained as a psychologist in France in a university that predominantly used a psychoanalytic approach to the human mind, over twenty years ago. My hubby went to med school in order to be able to practice psychiatry.Both of us downstairs when I was working were doing the SAME THING, regardless of training (psychotherapy/psychoanalysis...)Ummm... I HAVE SERIOUS DOUBTS ABOUT THE POSSIBILITY OF TEACHING PSYCHOTHERAPY.Now.. you can LEARN IT. But being able to learn it does not mean that you can teach it...When I was reading Freud, I fell off my chair in ADMIRATION over his capacity to differentially diagnose tabes and the symptoms of his hysterical patients. He could do that because he was a damned fine clinician, and a neurologist.You learn clinical skills better as an M.D. (but are you still LEARNING THE ART OF CLINICAL MEDICINE IN MEDICAL SCHOOL in the States ?? Questions, questions...) than you do as a psychologist.I'm not sure that allowing psychologists to prescribe is going to do the... psychology profession very much good, Doctor Carlat...It may release the psychiatrists from the strangehold of tayloristic medicine, but it won't necessarily do anything about the industrialized medicine problem. Just... MORE people prescribing.Perso, I NEVER set up practice as a psychologist.For ethical reasons...Something about the... ORIGINS of psychology tend to bother me a little bit...LAST point, I promise..The truly GREAT thinkers in medecine, in psychiatry, in psychology were people who received a humanist education.When I was at university, 20 years ago, there was a young man who truly COULD NOT UNDERSTAND WHY it COULD be important to know something about... Plato. Shakespeare. Keats.Literature.Too bad.The greatest part of my experience (outside of my personal psychoanalysis and the analyses of my patients) I received through reading literature, philosophy and history. NOT SPECIALTY BOOKS.Because... we are dealing with the human animal, the human mind and that animal has a CONTEXT.It is not a hardwire system. (Not exclusively, at any rate.)

Dr John, I would be interested in discussing STUFF/LIFE with you in my saloon (if you have the time and the inclination..), at www.streetratcrazysaloon.blogspot.com(Sorry, I am too lazy to figure out how to work links...)Cheers.

Dr. Carlat, you have stated a convincing case, and given a prescient view of the future of psychiatry which I heartily agree with.

I was one of the psychologists who carried out the military project that trained a group of psychologists to prescribe. We followed those practitioners into their role as prescribers in a number of military and non-military settings.

Almost without exception the MDs who worked with the trainees were thrilled with their performance, and often reflected upon their superior performance and knowledge in prescribing.

The reasons were that highly selected and motivated candidates received exceptional training by peoople who where themselves expert clinician/ psycho-pharmacologists.

The candidates were already seasoned professionals, most having been in charge of psychiatric wards, or clinics, and senior officers with outstanding records.

Their training in the program included much of the medical training from the 2 clinical years of medical school (but I might add, also the anatomy and biochem courses.

The key in the training was the senior MD psychoopharmacologist who supervised their practicum with a wide variety of seriously ill patients.

Why assume more prescribing?Perhaps the greater question is how to impact the large portion of mental health prescribing that occurs in primary care. As a psychologist it has been frustrating to have patients come for psychotherapy only to discover they are on a short-acting benzodiazepine, prn, and a sleeper. Trying to differentially diagnose with factors such as mood swings, mood lability and memory problems, much less provide cognitive behavioral therapy under these circumstances is less than optimal. Or sometimes it is the person who has suffered on a sub therapeutic dose of medication for several years before coming in for psychotherapy because the medications have not resolved their symptoms. Or then there is the person presenting after giving birth to her third child in five years with a history of post-partum depression who also has a progesterone-coated IUD.

The pursuit of the post-doc masters in clinical psychopharmacology is often motivated by the need to become competent in being able to recommend changing, reducing increasing or removing a person from a medication regimen that may actually be inducing symptoms, rather than reducing symptoms.

I am grateful Dr. Carlat for your willingness to consider as we move toward increased integration in our health care system we must all review how we are educated and trained. In some states PA programs are now doctoral level as well as some NP programs. If we move toward competency based programs, perhaps we will find the basis for education with specialty branches emerging after a two year common education program. This is done in many other countries. Thanks for being willing to ask the tough questions.PhD & MSCP in Oregon

BTW: Not a single pharmaceutical dollar has been involved in the legislative process in Oregon, just a handful of very dedicated volunteers, most of whom have contributed their own hard-earned money and two very part-time lobbyists.

I am not convinced that giving psychologists prescribing rights is the way to improve psychiatry although I appreciate the sentiment expressed by Dr. Carlat. In particular, looking at things from the patient's side, I do endorse the concept of having one person in charge of a troubled person's care, hopefully someone who can really make inroads in unravelling the patient's problems and what got him to that point, using therapy and, if necessary, medications to get through short term crises. In my own experience I have seen therapists spend considerable wasted time cajoling, challenging, coaxing and even fooling the psychiatrists they work with to get them to back off on medication or agree to a taper. I know several therapists, in fact, who actually understand the long term havoc wreaked by meds and who are more sensitive to the confounding effects of treatment on problems than the treating psychopharmacologists. This is probably because they tend to see patients over a longer period of time than a psychiatrist. Psychiatrists often follow people only over short windows of time during which the medications appear to be working well. And in my experience patients are often unwilling to share with their psychiatrists the negative effects of the meds (they may not even know they are caused by the meds) as honestly as they do with their therapists.

Of course there are also therapists who call GPs and beg them to prescribe cocktails of psych meds at their recommendation. It's very much an individual thing. Some psychologists could well deserve to have prescribing rights while there are probably many psychiatrists who should have the right withdrawn. I have seen outrageous treatment prescribed by psychiatrists that literally makes my hair curl. So yes, as Dr. C suggests we are overdue for some radical restructuring of how mentally troubled people are cared for.

The problem is psychiatry fools itself into thinking the treatment paradigms they are using are based in science but if one really cares to look at clinical trials and how they are run there is a lot of fraud being perpetrated in the name of science. A clinical trial requires a pool of mentally ill patients; that usually means people who have already been diagnosed and treated. For the trial they have to go through a "washout" (aka abrupt withdrawal). So now there's a group of really troubled, agitated people in withdrawal and half of them are put on a placebo and half on a new addictive agent, not that dissimilar probably to what they had before. Guess which group does better in the 4-8 week window during which they are observed? Hint: it's not the group in withdrawal (on placebo). This is the kind of "science" that's being used to approve drugs and upon which clinical practice is based.

Psychologists are really the ones who end up observing the effects of the drugs. They are the ones in the trenches figuring out that something is amiss with current paradigms in psychiatry. If they really could be trusted to use that information constructively then let them prescribe. Hopefully it would mean they would spend a lot more time helping people off drugs than giving them more.

I would be concerned that, because of economic and social pressures, that psychologists would indeed start to do more "med checks" and less psychotherapy. Instead of expanding the role of therapy in psychiatry, psychologist prescribing might instead contract its role in psychology.

As a committed psychotherapist and as someone who believes that medications can be very helpful if properly used, I use my medical training all the time. As one of the other posters pointed out, the drugs don't just affect the CNS but also interact with other medical conditions, organ systems, and non-psychiatric medications.

I agree that psychiatrists should not practice internal medicine - I personally would never let a psychiatrist do a non-neurological physical exam on me. However, I do know enough medicine and physiology to suspect a medical disorder. A psychologist may not. I would know when and who to refer the patient to better than a psychologist would as well.

Just as an aside, did you know that out of the four psychologists who participated in the military's pilot program to train psychologists in psychopharmacology, two decided they had better go to medical school - and did!

Thanks to anonymous above Sara for pointing out that no pharma dollars were involved in Oregon. I am surprised, but glad to hear that.

One thing that strikes me here is how often labels are used as if everyone to whom the label applies behaves the same. "Psychiatrists" see patients for medications and do not listen to them. "Therapists" see patients more often and really listen.

I know psychiatrists who use hypnosis or biofeedback with their patients. I know therapists who I wouldn't send anyone to as all they see and hear are their own prejudices.

This seems to be a problem with language and the inability of a blog comment to be an in depth analysis. We have to use lablels, but don't have the space to move beyond the stereotype of the label.

For me, this post is like an accident, and I am a driver who wants to drive by without looking, but the carnage is just too vivid to ignore.

With the logic of this post, it seems to just validate the prior logic (much twisted in my opinion) of:

1. Managed care deciding which provider groups get reimbursed for what interventions,2. Social workers, as a group, getting approved for more clinical abilities than the training truly prepared for legitimately,3. the pharmaceutical industry creating psychiatric labels to validate the use of their medications,4. Non psychiatric physicians being more bold to prescribe psychotropics for complicated psychiatric disorders and practicing polypharmacy with greater frequency, without referral or consultation with a psychiatrist, and last,5. Psychiatrists practicing more med check interventions to a point of a sizeable percentage seeing 5-6 patients an hour for up to 6-8 hours a day.

So now we have KOLs (and per your increasing presence on the internet as a blog author at multiple sites of professional information can define you be viewed as such) being proponents for non medical trained providers becoming prescribers with what really is minimal educational preparation.

I assume you or other accredited commenters will call me wrong on my points with valid refuting data and documentation, so I will be interested to return to the scene of the crash in the next day or two to read so.

36 comments in just one day since the post made. Has to be a record for this site?

To move away from my earlier tongue-in-cheek critique, and to get more serious: I share a number of Dr. Hassman's concerns.

As a semi-retired psychiatrist who has been involved in this debate for nearly 20 years, I would respectfully submit that the issue has been muddied by several "red-herring" arguments and linguistic lapses.

First, the notion that we are merely debating who should "prescribe" is a profound misunderstanding of what pharmacotherapy and medico-legal responsibility entail. It is a bit like asking who should have "cutting" privileges--all physicians, just surgeons, or maybe specially-trained non-physicians?

In reality, there is no such thing as "prescribing", apart from a comprehensive understanding of the patient's physiology; metabolism; co-morbid medical disorders (such as liver dysfunction, thyroid abnormalities, etc.); concurrent medications as prescribed by otherclinicians; drug-drug interactions (including over-the-counter medications); history of drug allergies; and at least a dozen other medical factors that would take too much space to discuss. In short, there is no such thing as "prescribing" apart from the general practice and understanding of medical science.

The notion that the medical skills required to master these issues can be acquired without extensive medical training is, in my view, both unproven and potentially dangerous to the general public. Generalizations based on a hand-full of psychologists, trained under very carefully-controlled conditions--i.e., in the Department of Defense training program--are not sufficient to overcome this uncertainty, in my view.

We would need to evaluate several hundred psychologists, over several years, with careful attention to the kinds of patients they treated; how many of these patients had co-morbid medical illnesses; how many received multiple medications; etc. To my knowledge, we do not have such data.

Then there are the medico-legal issues: would "prescribing psychologists" be willing to assume full medico-legal responsibility for any adverse drug reactions incurred by their "patients"? Would they be willing and able to manage that well-known, gut-wrenching call at 3 a.m., in which the patient is complaining of a sudden, unexpected side effect of a psychotropic medication? (Psychiatrists routinely handle such calls, and accept the medical and legal responsibility of doing so).

None of this is to say that physicians in general or psychiatrists in particular have done a stellar job of mastering these fundamental medical issues. As a psychopharmacology consultant for over 20 years, I saw many "nightmare" cases in which the prescribing physician had made very serious errors, engaged in unwarranted polypharmacy, etc. But the solution to this is more rigorous training for primary care and psychiatric physicians--not, in my view, widening the practice of medicine, under the misleading rubric of extending "prescribing privileges".

Finally, I, too, lament the decline in the use of psychotherapy by psychiatrists in recent decades; however, many of us still provide this as an integral part of our practice, and many of us strongly advocate increased psychotherapy training during residency. I also believe there is plenty of room for collaborative work between psychologists and psychiatrists, building on and appreciating our respective strengths as mental health professionals.

Ronald Pies MD

Disclosure: Dr. Pies is now engaged in full-time writing, editing, and teaching. A full disclosure statement may be found on the Psychiatric Times website, under "Board Members"

I've been a psychiatric nurse for almost 20 of my 26 years as a nurse.

I think that medical psychotherapy is the gold standard. It has almost gone the way of the dinosaur.

I think the biggest mistake that was made in training psychiatrists was to optionalize real clinical supervision, and the art of learning psychotherapy. It's amazing to me that anyone thinks its okay for a shrink to have skipped their own therapy.

Some of you may think that you don't need to learn anything about therapy, especially if you are only interested in psychopharm.

Newsflash to those shrinks who passed on the therapy and think it doesn't make a difference: It really, really shows. We ALL know who you are.

Maybe you don't need all that medical school stuff to safely prescribe psychotropics. But let me tell you, there is not a day that goes by that I don't use, and that I'm not thankful for, my extensive critical care experience. (I am NOT in any way equating my medical/psychiatric experience with those of the physicians here. I'm pointing out a kind of parallel.)

As for those of you who think that Danny's opinion amounts to the dumbing down of psychiatry, here's another newsflash: forget it. It already happened.

It happened when your "key opinion leaders" allowed their honesty and integrity to be bought and used. They're really just highly paid and educated prostitutes (no offense to any "working girls" who might be reading).

Everyone of your peers who swallowed the Pharma kool-aid and dumped therapy for ineffective but not-so-benign medications devalued psychotherapy and took it as its victim. And made a huge contribution to the dumbing down.

Having a part in restoring psychotherapy as the first-line psychiatric treatment would be something to be proud of.

Just my not-so-humble opinion.

Challenge the "evidence". You know it's crap.

Go back to the roots of the discipline. Hone your craft. Take it back. You know that there is no better gift to the mentally suffering than competent psychotherapy.

Sigh. I have once again successfully veered off the topic. I just needed to respond to some comments.

Danny, so glad to hear you are on the mend.

Confidential to Autumn: The CCU is actually the only place in a hospital where a nurse can diagnose and treat. And I don't know ANY nurses or NPs who think they are equal to physicians.

Though I must admit, I think those who buy the Pharmaganda hook, line and sinker are pretty stupid. They would not be prescribing for me.

Could not these prescribing psychologists "risk out" patients on multiple meds, those with a complex presentation, patients experiencing unusual side effects, etc.? And wouldn't it be in their best interest to do so?

I am thinking of how nurse-midwives in my area accept only low-risk patients and refer others to OBs. Patients are also referred if they develop complications at any point in the pregnancy, and an OB is always on call for the delivery. I am not understanding why psychologists and psychiatrists couldn't work together in a similar manner.

Oh, bad idea! Commenting from the perspective of the immigrant communities we work with, one of the fears frequently expressed is that their children are being diagnosed by their teachers/school administrators and prescribed for (off label) by their pediatricians.

The 12/12/09 Duff Wilson NYT piece on the 4X greater rate of psychotropic prescriptions for children on Medicare compared to those on private insurance should be a sobering wake up call for everyone with any doubts (self or otherwise) as to the unquestionable sanctity and wisdom of the medical profession.

Letting one more group of 'experts' get their fingers into the drug cabinet is not a solution to our mental health (or educational/social) problems, it's just one more step along the path to the United States of Zombie - and realizing the dream that instead of the hard work of therapy (with pharmaceuticals as an adjunct controlled by physicians with, hopefully, some level of expertise) the little Lunestra butterfly will soothe us all!

Beyond this, the collusion of psychologists in the torture of prisoners in Iraq and a couple of years of the flip-flopping by the APA over the role of the "Behavioral Science Consultation Teams" (Orwell, bite your tongue) is reason #11 for placing this idea in the "What was I thinking of?" file.

Sorry to come on so strong, but the solution lies in a total overhaul of health care and how it is prioritized and supported by our society, not adding another level of provider in order to lighten the load.

I could not agree more to this post! I am a clinical psychologist and also a psychopharmacology teacher and it really bugs me why can't I make a specialization course that would allow me to prescribe medications, since psychiatrists can take courses on clinical psychology!

I really like your blog and look forward to read your book, I will import one all the way to Brazil!

When I was practicing psychotherapy/psychoanalysis FOR MONEY, I used to tell my patients that it had taken them many many years to become who they had become, and that thus, it was going to take some, uh, TIME for them to get out of the ruts they were in.Psychotherapy requires the admission that it's going to take time to get somewhere.Now... pill popping, that's... MAGIC, isn't it ?Instantaneous ?Lots of questions, lots of SOUL SEARCHING to understand why we have decided to privilege magic, instantaneous ORAL results over PROCESSES that evolve over time.And why we (psychologists AND psychiatrists, because psychologists and psychiatrists are MEN AND WOMEN living in a society that privileges instantaneous results too...) seemingly cannot accept solutions that are structured as BOTH/AND rather than.. EITHER/OR...This is why I prefer the psychoanalytic (lacanien) take on things.Because, in order TO BE A PSYCHOANALYST, YOU HAVE TO HAVE BEEN ANALYZED BY SOMEBODY ELSE.That little sentence deontologically SEPARATES psychoanalysis from all the other psy professions in the nature of its transmission. As the last "anonymous" reminded us, by the way.THAT is why I set up practice as a psychoanalyst.And THAT is STILL what gives the GREATEST LEGITIMACY to psychoanalysis among all the psy professions.Don't get me wrong. It's not a guarantee against abuse. And psychiatrists/psychologists who have been in therapy CAN be better psys than their counterparts who have not been in therapy.But... their "professions" are not structured to afford them this particular legitimacy, the way that my (ex)profession was organized... over here, at least, and at this time. Still.

Re: Dr. Pies - "In reality, there is no such thing as "prescribing", apart from a comprehensive understanding of the patient's physiology..."

Notice that Dr. Pies focuses exclusively on the mechanics of pharmacology and physiology. However, a comprehensive understanding of a patient’s physiology should be a necessary but not a sufficient condition for prescribing psycho-pharmaceuticals. The parallel necessary condition is an understanding of the patient’s Belief System.

I.e., Why do they think they feel like they do? What exactly makes them unhappy? What do they think has to change to improve the quality of their life? What can they do now to help themselves apart from medication? Psycho-pharm can only be prescribed in the context of that holistic understanding of the patient’s belief system.

And that kind of careful elicitation apparently is not conducted with skill, or even at all by many psychiatrists. Dr. Pies implies that physiology is the key. Psychotherapy is a “nice to have”. And he’s a psychiatry KOL. So there’s your problem...

I have an LCSW, have practiced psychotherapy for several years, one of my majors in college was in Biology, what makes a psychologist more qualified than I am? If this is about increasing the number of mental health care providers able to prescribe, they should definitely be giving the opportunity to all psychotherapists. A rigorous 2 year psychopharm curriculum for SW's should be just around the corner.

Dr. Pies - I am a psychologist who has received many calls in the night. Usually they are from a desperate person who wants to die.

Personally, I don't want prescription privileges. I love what I do (despite the occasional midnight phone calls) and work well with several physicians, APRNs, and psychiatrists. Observing what has happened in the practice of psychiatry over the last 25 years, I would fear for the gradual usurpation of my psychotherapy practice. The temptation to prescribe medications that promise quick relief might begin to take over a deeply meaningful work life.

However, I have worked extensively with psychiatric APRNs and CNSs and I expect that well-trained psychologists would also do a great job. I don't need medical training to suggest a workup for thyroid or other physiological issues in a seemingly depressed person. Without medical training, I have questioned drug interactions and sent the client back to the pharmacist and physician. I'm sure that thorough training will produce thoroughly competent prescribing psychologists.

Hi, Danny--As you may know, I make it a policy not to respond to unsigned, anonymous, or pseudonymous attacks posted on websites. I consider them cowardly and irresponsible (and there, you have your problem).

Nevertheless, I feel compelled to point out that anybody even remotely familiar with what I have been writing and teaching for the past 30 years would know that,for me, an understanding of the patient's psychology, world-view, and "inner life" is absolutely critical to treatment. It is no less (and no more) important than fully understanding the patient's physiology.

Psychotherapy, in particular, is not something "nice" to have, but rather--as I stated earlier--an "integral" part of psychiatric practice. To the extent that our practice model has moved away from this position --owing to market forces and other factors--we have been diminished as a healing profession.

For those willing to ignore easy caricatures of psychiatry, and actually do the work of understanding what pluralistic psychiatry is, I would direct them to my article on "The Anatomy of Sorrow", published in PEHM.

To tell the truth, I sort of don't care if medications were over the counter. Don't care if I never have to write another prescription again for the rest of my life. My doctorhood is not defined by the motion of my wrist. Let everyone buy what they want and take what makes them feel good, I don't care.

The psychologist idea doesn't go far enough. Tired of naturopaths and lay midwives getting patients money and love, while we get the difficult patients, often the nasty ones and the ones who don't want to pay, and the OBs get the emergency at 4AM and the lawsuit. Everyone else gets the fun part (the therapy of any type) and we get to push drugs. Great. How intellectually and emotionally satisfying.

The war as I said before has already been lost, we just cling to some notion that we still have some value. No one values us. It's over.

I wasn't attacking anyone. I was merely restating a common archetype of the psychiatric practice model that has been framed out by many others.

The issue is not a lack of recognition that holistic psychiatry is a good thing. It's that holistic psychiatry is so rarely practiced. For whatever reasons. The result is often an unsatisfying drug-centric solution across the continuum of dysphoria or whatever. That's not just me talking. That's you guys.

Arguing over other professional classes getting prescribing privileges does nothing to address the issues within psychiatry that Dr. Carlat identifies. I think he is (rightfully) baiting psychiatry with that proposition.

So psychiatry apparently has two challenges. The first is a "meta-challenge" which is the resolution of bifurcated belief about psychiatric service quality right now. I.e., is the de facto archetypal therapeutic model satisfactory? And if a critical mass of psychiatrists agrees that it is not, the second challenge is generating a shared commitment and investment toward positive change by psychiatry’s stakeholders.

Are those challenges legitimate? If so, what are some actionable ideas to address them?

And about me. Not cowardly. Sometimes irresponsible. Always a dilettante.

P.S. Re: autums_leaf

There's an old saying in Decision Analysis that if there are no alternatives, there is no problem.

But I see that Dr. Arpaia and others have formulated successful holistic models.

We here at the University of Tennessee Health Science Center in Memphis have a strong emphasis in psychotherapy, especially in the outpatient year. Even though I am no longer training director, I personally see to it.

Dr. Pies, as an FYI, people like me who are anonymous do it to protect ourselves from employers who will do a search of the Internet. It is not because we are trolls as you seem to imply.

In the past, I have never attacked you. I have criticized your posts but as long as I don't flame you which I haven't, that is fair game.

I would think as a psychiatrist you would understand that better than anyone.

Kim Smith makes a good point about what makes a psychologist more qualified than him/her to prescribe meds. The downside is as people have alluded to is if every psychotherapist gets to prescribe meds, there goes psychotherapy and any options for people who don't want meds.

By the way, you psychiatrists who post on this board, do you work with patients who don't want meds? Just curious.

Finally, as one who is tapering off of psych meds and who feels that most psychiatrists (not all) are clueless about how to taper patients off of them, what makes you think psychologists are going to be better at this? You do realize that some people don't want to stay on meds for life, right?

Most of you probably know who David Healy is. I wonder how many of you know that he has actually proposed that SSRIs be sold over the counter. I suspect it's very much like this blog's proposal that psychologists be allowed to prescribe. It's meant to turn current thinking on its head about what's needed to solve current problems in mental health care.

I actually went to a psychiatrist for therapy for a fairly extended time after a great tragedy in my immediate family. I gave up going to her finally, not so much because she wasn't a good therapist, but because the people coming out of her office before me and those going in after me all looked like zombies, with flat affect and blank expressions. On top of that she was a bit careless about getting rid of the drug company paraphernalia -- the mug, the pen, the clipboard, even the clock. (This was several years ago.) It got me down to the point where I just couldn't really trust her anymore despite the fact she always listened respectfully to my views on the adverse potential of psychotropics.

I would like to thank Dr. Pratt for her comments, and for giving me the opportunity to highlight the problem of undiagnosed medical illness in so-called “psychiatric” patients. It has been known for decades that patients appearing in emergency rooms and outpatient practices with apparent “psychiatric” problems—depression, anxiety, psychosis, etc. —frequently have undetected neurological, cardiac, endocrine, or other medical disorders that cause or contribute to their “psychiatric” problems. One recent study (Rothbard et al, 2009) of 588 psychiatric inpatients found that 10% were HIV positive; 32% had hepatitis B, and 21% had hepatitis C. Even on the inpatient unit, the treatment team missed a considerable proportion of infectious disease (95% of hepatitis B cases, 50% of hepatitis C cases, and 21% of HIV cases) and metabolic disorders.

You write, Dr. Pratt, that you “… don't need medical training to suggest a workup for thyroid or other physiological issues in a seemingly depressed person."

I have no doubt that you are a very astute and careful clinician, Dr. Pratt, and aware enough of undetected medical illness in those you treat to send them for a medical evaluation when their symptoms warrant it. But (as I am sure you would agree), this awareness is a far cry from having the requisite medical knowledge to undertake the independent medical-pharmacological treatment of a person with, for example, severe depression.

As for the sort of “training” you allude to—for example, several hundred hours of course work in physiology, pharmacology, etc.—it remains entirely unclear, in my view, that this kind of program will adequately prepare a psychologist (or anybody else) for independent medical practice. If you read the excellent papers by Robiner and Pollitt, I think you will see why this is so. I have sent these papers to Dr. Carlat and I hope he will find a way to link with them, so that all readers can see them. The references follow at the end of the second part of this message. [end part 1]

Again, let me be clear: when you hand a patient a prescription for a medication with potentially serious side effects and interactions, you are without any question engaging in the practice of medicine, with all its medico-legal privileges and responsibilities. Psychotropic medication is not a “set and forget” pill. Pharmacotherapy is a week-by week, day-by-day process of careful monitoring—not only for potential side effects, but for the effects of concurrent medical illness; infection; changes in the patient’s kidney or liver function; changes in sleep, weight, and appetite; effects of newly-introduced antibiotics or heart medication; and a myriad of other medical factors that pour in to one’s office, every day. It is not enough to say to the patient, “Well, if you have any problems with this medication, go see your primary care doctor.” (When I was actively seeing patients, I had my blood pressure cuff and stethoscope always handy, and would often do circumscribed neurological examinations to check for medication side effects). I have great respect for psychologists, psychiatric social workers, and other mental health professionals, from whom I have learned a great deal. But before we acquiesce in a huge, public health experiment such as that proposed by some on this blog site, we need to investigate its safety and efficacy in a large, medically-supervised study, involving hundreds of non-MD “prescribers” and hundreds of patients who have given informed consent. We have nothing remotely approaching that kind of data. What is being proposed with respect to psychologists is analogous to allowing “non-engineer bridge-builders” to construct our nation’s bridges, after they have had “appropriate course work in bridge building”. The problem must not be trivialized to one of economic “turf battles.” There are vital scientific and public health questions that lie beneath that turf. We need to answer those questions before we create a very rickety, and potentially dangerous, two-tiered system of mental health care. Ronald Pies MDReferences: Rothbard AB et al: Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients. Psychiatr Serv. 2009 Apr;60(4):534-7.Robiner WN et al: Prescriptive authority for psychologists: a looming health hazard? Clinical Psychology: Science and Practice. Vol 9, no. 3, Fall, 2002. Pollitt B: Fool’s Gold: Psychologists Using Disingenuous Reasoning to Mislead Legislatures into GrantingPsychologists Prescriptive Authority. American Journal of Law & Medicine. Jan 1, 2003 [available at:http://www.highbeam.com/doc/1P3-536802481.html]

AA, if it were up to me, I would give very little medications. I've worked in different settings including private practice, inpatient units and outpatient clinics, and it is always the patients as well as the therapists, SWs , NPs and the medical directors who want me to prescribe medications - the more the merrier - and to confine my practice of medicine to prescribing. And signing forms, of course.

I am always trying to lower the burden of patients polypharmacy and keep medication to the minimum necessary to function or relieve suffering but I am met with complete resistance. Most of all from the patients themselves. There are psychological, social, cultural and brainwashing reasons for this but I don't think we should get into all that here.

I always am trying to take non-medication approaches (therapy, relaxation, working with the patient on restructuring life and activities) but the patients are not interested. They either want to hear nothing about any of this, just get their pills and go, or they have someone else to work with them on all this - a "therapist". Medical directors have admonished me for doing anything other than my role which is, I learned, to be a "med-checker".

There will be no haven from drug pushers then, because psychologists will prescribe with a zeal that will make psychiatrists pale, and pharma will court them equally as egregiously.

People who were lucky enough to see only a psychologist in private practice and achieve some kind of recovery without drugs, will have done so without being stigmatized and labeled as psychiatric patients in their health records. For the rest of their lives. That label costs, not only with social stigma, but for future employment and health insurance.

Leave psychologists without the ability to prescribe. After all, recent studies show there is no real evidence for anything psychiatrists prescribe anyway. No good effect better than placebo. Only negative, all around.

I think Dr Pies makes some reasonable points but he also appears to be looking at psychiatry in an idealized manor and not at all what actually exists in the real world. I have been in a hospital and out pt setting for 20 years. I rarely if ever see pts with psychiatric complaints outside of acute emergency changes in mental status that have not already had extensive work ups including thyroid, liver tests a complete CBC and often a CT. I wish he was correct in his implication that there was a vast sea of people on psychotropics who just are mis- diagnosed and have medical issues psych Drs are finding.I watch psych Drs. This rarely if ever happens. The fact is the vast majority of pts I see are young and healthy and have absolutely nothing wrong with them other than they appear to have learned to filter their emotional troubles through the lens of modern psychiatry and the internet check lists they come across and now believe they have a disease that needs a Dr. They do not like it when I say they do not and there is scant evidence the garbage pail of meds they are on do not help and neither do many of my fellow Drs.I have news. There already is a two tier system. Primary care docs take advise from non-medical therapists on meds(and reps too) and NP's prescribe loads of drugs. They all seem to have taken their cues from mainstream psychiatry working in concert with drug companies. I am sure in some microcosm everything Dr Pies has written is correct but this is not at all the real problem. We don't need psychologists prescribing. Dr Pies is right. We need everyone else to quit f.....g prescribing.

There will be no haven from drug pushers then, because psychologists will prescribe with a zeal that will make psychiatrists pale, and pharma will court them equally as egregiously.

I couldn't agree more. Imagine the enormous market for psychotropics that this would open. And if a psychiatrist with 8+ years of medical training can be swayed by a college grad who's taken a pharma training course, then there's no hope for the therapists.

I think the (unfortunate) underlying issue is that most people-- psychiatrists, psychologists, and patients alike-- opt for the "quick" and "easy" (and dare I say "lucrative") way out.

I think we all intuitively agree that a lot of psychological suffering can be alleviated with good therapy, but this takes time. It's much easier (or so we think, in our short-term mindset) for everyone involved to simply get a drug and be done with it. Psychologists might hold out a bit longer before picking up the pen, but once they do so, they'll be as Rx-happy as my psychiatrist colleagues.

I posted earlier asking how many psychiatry residency programs have a serious psychotherapy component in their training programs. 63 posts later, I count respondents naming about 6 training programs. Which is what I figured. So take an average residency class of 8 psychiatrists to be and we arrive at a whopping 48 psychiatrist a year being trained seriously in psychotherapy. Yeah...that will fill the need for sure! LOL.

well said per your part 2 comment today: "we need to answer those questions before we create a very rickety, and potentially dangerous, two tiered system of mental health care."

Actually, minus the medication factor, we have a multi tiered system already that has mistakenly tolerated less than adequate providers, not only between mental health services like psychology, social work, and other therapy endeavors, but even within psychiatry itself. And, we have done a terrible job of policing ourselves within our profession, and the other post from Dr Carlat today shows how inconsistent the leaders still are!

I am going to finish my comments at this blog with this last statement, that will enrage and provoke other negative feelings, but it needs said and I hope will be published by Dr Carlat, as it is intended to enlighten in the end:

the negativity and attack by the assorted commenters I have come across at various blogs may have some legitimate grip, but, in the end, I truly and sincerely believe a lot of the dissenters of psychiatry are fueled by hate and distrust that does little good for the objective and unbiased readers who I suspect rarely comment. My profession is not perfect, it has room to improve, and we as doctors need to hold both ourselves and our colleagues to the higher standard of expectation and responsibility I feel has profoundly deteriorated since I finished residency in 1993. There is no benefit or good to look the other way when we know a colleague is impaired, unprofessional, or downright incompetent. Having taken a stand years ago at a place that tolerated such negative qualities in providers before I arrived, and colleagues continued such poor judgment, even after I filed complaints with the state board, taught me a very valuable lesson, which I already knew, but learned again. Deeds, not words define us, and we should not accept poor or substandard deeds.

Psychiatry has been repetitively guilty of this, especially per the role of psychopharmacology these past 15 years. If you have a soul and care about the status of patient care these days, you should take a stand, at least for your patients! Because, we are as much advocates as we are clinicians. And we need to remember this!

Thank you for the opportunity to comment here for the past year plus. Between the rough ride of these blogs and the devastation pending from health care deform legislation, for medicine in general and psychiatry specifically, I need to find more nourishing and optimistic sources of respite.

autumns_leaf - There has been a convergence of many factors that has created the situation we are talking about: greedy pharmaceutical and managed care insurance companies, naïve and corrupt experts, twisted science, and guilty parents who would rather label their children as bipolar than to look at their family interactions.

A long time ago psychiatrist Leon Eisenberg noted that psychiatry over its history has switched back and forth between brainlessness and mindlessness, and unfortunately we are now in the mindless phase. I have a book coming out on this subject in a few months.

Medical Psychotherapy is that which is conducted by a psychiatrist. A genuine MD.

To the LCSW who needs a reason for what makes a psychologist more qualified to prescribe than a CSW:

DO YOU WANT THE WHOLE LIST, OR JUST THE TOP TEN??

Note that this doesn't mean that I think psychologists should prescribe either.

I completely agree with Dr. Hassman's assessment on this point.

Everyone who attends these drug lunches--who think they're being educated by that Pharma-trained Art History major--come away only with the thought that prescribing is a breeze, anyone can do it, there's no other factors to weigh, no worries about medical comorbidity, polypharmacy.

To the poster who asked the psychiatrists if they have any patients that don't want meds:

Maybe shrinks in private practice have a few people who don't want meds. At a county mental health clinic, there is almost no one who doesn't want meds. Those who don't have therapists who tell them exactly what meds they should be on before pushing them to the psychiatrist, putting the psychiatrist in the awkward position of having to explain to the client why their therapist's recommendation will not only be ineffective but may kill them as well.

Most of our therapists have little desire to function within the scope of their own license. They are much happier being junior prescribers--with none of the risk attached.

Between drug lunches for therapists and DTCA, everyone is a diagnostician. Teachers, therapists, next it will be the cafeteria ladies.

It takes considerable knowledge of a subject to have an awareness of how much you DON'T know about that subject.

I'm very aware of how NOT qualified I am to prescribe.

Sorry to get so contentious, but some of this stuff really gets under my skin.

Wet nurse: Can you direct me to a series of papers or technical manual that clearly defines the technique or specific interventions that differentiate "medical psychotherapy" from all other forms of psychotherapy? Being done by a DR does not define anything. I am a Dr and cut my own yard. This does not make it "medical lawn cutting" when compared to the lawn service who does my neighbors but lacks my advanced degree. After you have educated me on the specific technical interventions in "medical psychotherapy" that only a physician can perform please educate me by providing me some definitive research in outcomes in regards to the superiority of "medical psychotherapy" that would lead you to your conclusion that it is clearly superior to other forms of TX and hence the "gold standard". Thank you.

The main reason for my interest in this idea of delegating simpler med checks (that is, in stable, otherwise healthy patients; destabilized patients should certainly be sent back to the MD) to NPs or psychologists is that i'm wondering if it could free up psychiatrists to spend more time on initial evaluation, complicated cases, and especially, inpatient treatment. As a five-time inpatient in four different facilities, i have rarely spent more than ten minutes at a time with a psychiatrist (usually five minutes spent answering yes/no questions hurled at me in a rapid-fire manner), and i believe this is the main reason why my medical record contains such such a variety of inaccurate and wildly divergent diagnoses. It bothers me that patients in acute distress may receive minimal medical attention, while i was allotted 20-30 minutes for med checks that consisted of rehashing a bunch of stuff my therapist was already aware of.

I would be interested in knowing if i am missing some important piece of information. For example, maybe simple med checks are not really as simple as i imagine them to be. Or maybe you are expecting a large influx of new psychiatrists in the years to come.

Sarah, there is no such thing as a simple person. Your experience in inpatient is probably a result of the forces David Allen mentioned, and mainly mangled care. There should be no such thing as a medcheck.

What the heck is it anyway? Can someone explain it to me? I must be too stupid to get it. I examine patients, I don't 'check' 'meds'. This 15 minute 'medcheck' thing is perverse and evil. And everyone who colluded with it, which includes 99% of everyone working in the system, should be locked up n a very small cabin with Rush Limbaugh as he makes his way to Costa Rica.

I think your analysis is short sighted and not helpful in our current financial climate. How can we believe that psychologist prescribing led to no adverse events? If true they must do it better than we, since we have adverse events. Either the data is untrue or they are (for now) limiting themselves to the simplest of cases.

Also, do you really believe that only focused trade school type education is needed? Why require a college or even a high school degree? Why not have trade schools that train people only in psychotherapy and psychopharmacology and in no more than is needed for a trade?

In my view wider training is needed to have good practitioners capable of treating difficult patients. Medical school trains psychiatrists to be sensitive to the medical effects of drugs they prescribe. Internists often are not familiar with psychiatric facets of medication or even medical illnesses. For patients with medical problems or side effects of medication, medical training as well as psychiatric specialization is important. College is important to give a broader background including exposure to the humanities and learning to think critically. Graduate school for psychologists gives a different but not irrelevant background. But it does not train people in a medical perspective needed for medication prescription.

At a time when there is a push to do everything cheaper regardless of quality, I do not think this analysis is helpful or complete. It can too readily be misused in the service of an excuse to sacrifice quality merely to save money.

Let's just leave the prescribing to physicians; and let the psychologists do the therapy. Psychiatrists are not trained in psychotherapy any longer. Those few psychiatrists who want such expertise end up going to the analytic institutes for therapy education. But those are far and few. Let the therapy be done by those trained to do so -- PhD's and LCSW's.

autumns_leaf: I see what you're saying. Maybe i overstated my case. My current psychiatrist, and the one before that, use the 20-30 minute sessions to form as complete an individual picture of me as possible. I respect what they do and am in no way suggesting that time spent medically evaluating stable patients is not valuable. I consider myself fairly stable currently, am taking no medications, and see only a psychiatrist; i've seen good therapists and good psychiatrists and would never attempt to equate the two. (Sloppy, clueless, or misguided psychiatrists certainly exist but are another issue altogether.)

What i am saying is that in the current situation as i see it, people are bound to get shortchanged. I am rereading the comments to see if anyone has proposed anything that can help this situation.

It did not occur to me that insurance companies might reimburse less for time spent with inpatients, though, or something along those lines -- Is that the case?

(When i was younger, my psychiatrist visits could probably more fairly have been termed "med checks", as those doctors did very little adjustment of my medications -- despite my having been actively suicidal or at least self-destructive for most of those two years -- and occasionally showed signs of not knowing me very well; for instance, one of them tried to convince me that i was having auditory hallucinations. Maybe "med check" is just another way of saying that a particular visit is pointless or severely constrained?)

Dr. Carlat: What make you think psychologists will continue to provide psychotherapy after they obtain prescribing privileges? I suspect they will move in the same direction as psychiatrists and for mostly the same reasons. Health care costs too much, and one way to reduce costs may be to increase the number of providers. We'll have to do that anyway if we expect to provide care to all those who currently can't get it. We can either restrict prescribing to physicians, hoping that we thus maximize quality, or sell all the drugs over the counter, hoping to maximize access. We will end up somewhere in the middle.

What I think got us into this mess is overemphasis on psychodynamic psychotherapy and psychoanalysis in psychiatry. If we intend to keep psychotherapy at the core of what we do, we will need to master CBT, family systems, and other methods. Psychologists will face the same problem, but many of them already excel at psychotherapies that really work. And I predict that psychologists who prescribe will treat the easiest cases, most likely to benefit from the placebo effect.

The training of new psychiatrists should focus not on turning out psychotherapists who can prescribe, but physicians with expertise in biological psychiatry who also excel in dealing with the psychological problems of the mentally ill, but not with endless obligatory weekly 50 minute sessions.

You state that we cannot make more than $300 per hour seeing patients. Even if you charge $100 for a medication management visit and can do 4 in an hour, both conservative numbers, you get $400 per hour.

More on why I believe independent treatment makes sense for patients and psychiatrists:

You hit on an issue that is central to this debate. Should psychiatrists define themselves as purely biological psychiatrists, leaving the therapy to those with other training? Or should we move in the opposite direction, toward being integrated practitioners, offering both medication and therapy treatment to our patients.

In my opinion, most of my patients would do better with integrated rather than split or collaborative care. Of course there are plenty of exceptions. There are patients who take their Celexa like a vitamin every morning and that's all they need to prevent depression. These patients don't want or need therapy, and I would never force them to have it.

But I'd estimate that 60 -70% of my patients do better with a combo of therapy and meds. The question is whether split treatment works well enough for these patients. I can think of many patients in my practice who do fine in this model, but many others who do poorly. I don't have time to "collaborate" with the therapist, and vice versa. I learn, for example, that the patient has been abusing narcotics a year after the therapist found out. Or I learn the the patient has been suicidal after overly intensive therapy sessions, and the therapist had no idea.

I believe there is a place in our professional landscape for a "Doctorate in Mental Health" (a name borrowed from the defunct UCSF program of the same name)which would be a unique training program that interweaves psychopharm and psychotherapy training from day one. Such a doctor would generally be more qualified to treat psychiatric patients than either psychiatrists or medical psychologists as they are currently trained.

The history of medicine is replete with new professions forming as we understand better how to match up certain medical tasks with certain kinds of training. The creation of colleges of optometry in the 1890s is just one example, in which it became clear that we needed a profession other than ophthomologists to prescribe glasses--gradually, optometrists have expanded their scope to prescribe and do simply surgery.

I believe it is time in the history of psychiatry for us to establish an entirely new profession and new training program.

Hey moviedoc: Can we please stop blaming Freud and psychoanalysts for the mess we have made of our profession by selling our souls (and ids, egos, and superegos) to Big Pharma? Please! CBT and DBT, OK! Great therapies with specific populations and disorders. But me thinks that psychodynamics is still a wonderful model to understand the motives for behavior, and sometimes even mood and anxiety symptoms. Stop bashing Freud for what has taken over the field: Pure greed and sociopathy amongst our academic chairs and key opinion leaders!

A problem is that even if a new profession could be developed that trained people in both psychopharmacology and psychotherapy as well as the background in the humanities, medicine, social sciences, biological sciences, critical thinking etc. necessary for an ideal practitioner, psychologists are not currently that profession. So that is not a reason to give psychologists prescribing privileges without adequate medical training.

Also, psychiatrists will in essence commit professional suicide to give psychologists prescribing privileges. Similar arguments were made in the 1970s as psychiatry gave up most of psychotherapy gradually to less expensive psychologists.

Also, almost every profession requires those entering it to get background training with others going into other areas of study. Should each profession start training people for the profession with specialized training at the college level before students have sufficient exposure to know what they want?

Since as you say psychologists get most of their current training in experimental psychology why not give any prescription privileges to only graduates of psychology professional schools with who get more training in psychotherapy but not academically oriented PhDs or give privileges to marriage and family counselors with a crash course in psychopharmacology? Why any psychologist?

We also need believable data. To suggest that psychologist prescribers have had no untoward events is just not credible when everybody else has patients with problems. It makes one think such claims are dishonest or intentionally misleading and requires an investigation of this so-called data. In my opinion it does a disservice to meaningful discussion to quote such "data" as if it is credible. This data should at least get scrutiny equal to drug company claims before it is disseminated.

If that new profession means returning ? to a holistic way of SEEING the patient and dealing with the distress that he/she, in line with our current social.. prejudices on the subject call "mental" or "psychiatric, why not ?But I see little curiosity here so far in trying to understand the current oral fixation in Western society, what it means, and how it relates to a culture of pill popping, for example.For me, any such training should be not just technical school, scientific type stuff, but humanistic, encouraging curiosity and.. humility in the practitioner. Holistic means... looking at a human being as a whole.By the way.. y'all might be interested in cracking open Paul Tournier's books for a glimpse of holistic medecine.Tournier was a Christian G.P. working in the 1940's in Switzerland who obtained some miraculous results with his, uh, mentally distressed patients.Even if you DESPISE the idea of a Christian doc, and think it's quackery, it's worth your while seriously OBSERVING Tournier's attitude towards his patients, and the way he deals with the transference phenomenon. Exemplary...for those with an OPEN mind..

It's funny. Every time psychiatry has a crisis in faith it seems to get up on its box and start screaming things about the the holistic approach or the biopsychosocial model. Who could be against that? What does that even mean? My internist is a nice guy. He talks to me and makes an attempt to listen to my complaints as I see them. That is nice. So what. It's not a coherent model of understanding specific pathology or predicting anything. This is why psychiatry as a field is in crisis and there are arguments on this blog about so many other people doing our job.Psychiatry is an incoherent mess without any organizing principles. Moviedoc said we should be experts in biologic psychiatry. What is that? Given that not one mental disorder has any biologic test or can be confirmed by any objective method and our TX's are non-specific sledge hammers mostly what exactly is a biological psychiatrist? Is that someone who knows all about the drugs they give? Is it someone who can rule out medical pathologies? Maybe but it certainly is not someone who has any understanding whatsoever of the specific brain problems for the most part of almost all the pts psychiatrists are treating.I do not even believe this is really possible for most. If I beat my dog every day and he gets depressed and his brain functions different in an MRI do I really understand my dogs problem by looking at his MRI? Psychiatry exists as a social entity for processing problem behaviors. It is not going away soon but it's identity crisis is not either or new. You cannot be all things to all people. My feeling is they should add a 1yr fellowship to the neuro training for those interested in taking care of such pts who have an interest in pharmacotherapy. Having Drs spend most of their time teaching CBT or any "psychotherapy" for that matter is a waste of medical school which has gotten VERY VERY expensive. Today in the Drs lounge there was an article taped to the board on how nurse anaesthetists are now making more than primary care docs. This will all be about money in the end and Drs will not be paid to spend lots of time talking to pts. We better get over it and come up with plan B.

Listening to someone is not 'nice'. It's not 'so what'. It's the core of the matter. And if you don't need an M.D. to do it, why do you need any degree at all for it? Why have any sort of therapists? Why not have all meds OTC and abolish any sort of licensure for psychiatry, psychology or psychotherapy? We already have case managers doings consults. Why not have high school students do them? Why have consults at all? It's all pointless, after all.

I will "sign off" this discussion by thanking Dr. Carlat for provoking a useful debate, and by directing interested readers to my recent editorial on the Psychiatric Times website:

http://www.psychiatrictimes.com/display/article/10168/1545667?CID=rss

Both Dr. Carlat and I want to see our profession undergo "reform" and perhaps even re-birth. Dr. Carlat has used the issue of psychologist prescribers as a kind of goad--or perhaps, cattle-prod!--to incite such reform. As a political-journalistic tactic, I can understand this, even though I think the whole notion of "medical psychologists" is both misguided and potentially dangerous.

Psychiatry will need to reform by changing itself, not by acquiescing in changes to other professions. To this end, I have advocated the creation of a broad, pluralistic discipline, which I have called "encephiatrics" (roughly, "brain healing--but it is really more like, "person-healing"). For a description of this, please see the link at:

http://www.psychiatrictimes.com/display/article/10168/1532271

as well as the superb article by our Tufts colleague, Nassir Ghaemi MD, in which he describes the "biological-existential" pluralism of psychiatrist Karl Jaspers:

Ah, but Doctor John...Must you understand and systematize brain processes in order to help patients feel better ?Is psychiatry (and I must insist that it is a big trap talking about abstract "psychiatry" and NOT incarnated individual psychiatrists...) about knowing a bunch of stuff or helping people ?And is knowing a bunch of stuff (in order to predict (!) going to ensure that you will help people by knowing this stuff ?I think not. I.. believe not.Maybe you can coordinate knowing lots of stuff AND helping people. But for sure, given that most people seem to be functioning in either/or mode these days, I am pessimistic. Systematizing is fun. (I notice, for lots of people at any rate...)It CAN BE a relatively harmless intellectual activity that channels our incredible drive to classify.But... it can seriously get in the way of helping people.Particularly when it becomes an end in and of itself, always a risk. And when it gets too much in the way of helping people, well, then those people are going to desert the psychiatrists' offices to find help elsewhere.This is already happening...

That's exactly it autumns_leaf, you don't need any degree to listen to people certainly not an MD. That is why psychiatrists compete for pts with priests and all sorts of various folks degree or not. I am not minimizing the value of human interaction but it by itself is not enough to hang a medical sub-specialty on.Psychiatry's philosophical special pleading in this area is unconvincing.Just telling people we are better than everyone else does not make it so. The practice of medicine has a long and complex hx but the idea of medical Drs being extra special at "talking cures" is a new one and an intellectual and practical failure. It just does not hold any water and it is dying.It was barely alive to begin with. The issue of meds is a different story and despite the arguments about how useful our contemporary approach is or is not with psychiatric drugs, you can make a far more compelling argument that a medical degree should be obtained before people get to pass them out. We need not allow the argument to degenerate into "reductio ad absurdum" speaking of high school students doing such things but we also must confront the realities of what is happening and has been happening in this field. There will always be a place for the physician/philosopher but if psychiatry wants to survive it has no choice as a "medical" field to reinvent itself as that. Like it or not this will not include a specially high paid niche for just talking to people regardless of how much we pine away for it. Maybe self interest makes me wish it would. As a tax payer I know its a crappy waste of money.

You say, "Psychiatry exists as a social entity for processing problem behaviors." I agree but only to the extent that we have become suicide police and held responsible for other behaviors. And we should abdicate those roles to the extent we can.

Biological psychiatry: I think it's like the term pornography. We may not have a great definition, but I think most of us know we're talking about what's left when you take away psychology. On the other hand I think psychology should be part of biology. The effects of drugs (aside from placebo) are biological. They do not depend on meaning, and neither we nor our patients must understand, or even explain, what makes them work. Serotonin reuptake is almost as useless a concept as transference.

What I know is that almost all of my patients report feeling better and functioning better when they take the drugs I prescribe (or when they stop taking the drugs somebody else prescribed, or they bought on the street). Not always on the first try. I believe I have some skills in doing this that I can trace back to my medical education.

This will certainly be about money, and politics, in the end. I hope my patients think it's nice to talk to me like your internist. Maybe we should train thoracic surgeons to be nice to talk to as well.

Moviedoc...God help you if "transference" is a useless concept to you...Those drugs produce different effects on different people according to the season, the time of day, the contents of the person's stomach, other drugs the person is taking... etc etc. Do you want me to go on ?Even if YOU think that "transference" is a useless concept, you might be interested to know that it is not a useless concept for your patients....Time to turn on the observing and thinking processes.You wouldn't want to be.. JUST a pill pusher would you ?

Dr. John, I think there is a certain quality to being a physician that no one who is not a physician can understand, and I do not know how to explain this quality. If among physicians you choose those that are empathic and open minded and so on (and I think many psychiatrists these days are as far from these qualities as you can get), you have something different from a great psychologist or a great SW. I cannot really phrase what this difference is, but I feel it in my bones.

I think biological psychiatry is a load of B.S.. We haven't a clue about what's going on there in the brain. OTOH, we do know how psychological and social things affect us. We know because we experience these things ourselves.

autums_leaf I agree with all you have said here and I think overall you and I would agree about far more than we disagree. Like you I think Bio psych is total BS.Current bio-psychiatry is disease mongering. Although incomplete and lacking any predictive value and not one bit scientific, I find numerous psychological models far more valuable in helping me understand people and work with them than anything psychiatry has produced in the past 20 years. Mostly I think psychiatry has regressed horribly and people are vastly over-medicated. Psychologists will go down this same road so anything that improves access to this approach I am against. If they can prescribe they will become afraid when dealing with pt distress and turn to meds more quickly than even now. To me I think that is the risk of psychologists prescribing not that it is too complex. If psychiatry does it why would psychology not go down the same road? I already see this with APRN's and all kinds of non-medical people pushing for meds when there is the slightest sign of difficulty.This is also what the consumer has been sold and now what our leadership has defined as "standard of care" despite the pluralistic double talk. As a body I am not at all sure what is left in our field that can be salvaged or how this will play out. We do our best for our pts and try not to give up.

Dr. John: Obviously I disagree with your criticism of biological psychiatry, and understanding a patient does imply helping them. Read Jaspers. Our profession should not be judged by how scientific it is. Science should be judged by how useful it is for our profession, which is not very. I do agree many patients are over-medicated, and there is a sad tendency to see every mood, thought or behavior as something to be tweaked with change in dose of med or snake oil (with little or no foundation - scientific or otherwise).

You're right, I do agree with you, Dr. John. :) Except that I think we're already finished. It's a real practical problem since all this training leaves us unqualified for anything else, unless you happen to have a different marketable skill set, such as being an electrician or an interior designer or a programmer.

Ok moviedoc I will give you that pragmatic position that we need to judge something on how successful it is not how scientific in particular in this field. That makes sense but in the end, I disagree with "truth is what works". Ptolemy helped men navigate the oceans but in the end was dead wrong. If this is the case we should stop with the endless and useless functional MRI studies and the pathetic attempts at marrying psychiatry to science. I do not see contemporary psychiatry as being at all successful. In 1955, the number of people disabled by mental illness in the US was 3.38 per 1,000, but during the past 50 years, when psychiatric drugs have become the cornerstone of care, the disability rate has climbed steadily, and has now reached over 20 people per 1,000. In children the rates have risen much more. Outcomes for psychotic disorders are better in 3rd world countries according to the World Health Org. This does not seem to support we are doing very well with the current "biologic psychiatry" model.

Dr. John: First my mistake. I meant "Understanding a patient does NOT imply helping them." Truth is beside the point here. Maybe Dr. Amen will find somebody's id (or transference) with a PET scan or fMRI. I doubt it.

You raise such an interesting question of how to measure our failure/success. I wonder if the disability numbers used the same criteria. I also understand that none of our treatments has affected the suicide rate in a positive way.

I'll argue one thing that really works though: buprenorphine for opiate addiction. That's what I mean by biological, but of course addiction undeniably has psychological and some would argue spiritual dimensions.

Moviedoc.How astounding you bring up buprenorphine! In 20 yrs I have never seen anything like it. I run an opiod addiction clinic. The success I see with this Tx is nothing short of amazing. What I am beginning to struggle with a bit however is the increasingly large group of people who get well on the stuff and lose any sign of "addiction" as far as behavior and lifestyle. God they go to work and take care of their families and I actually see functional recoveries. The problem is that after 9-12 months when it becomes time to slowly taper them many do not like how they feel. They do not report opiod craving nor do many relapse they just wish to remain on the medication for subjective emotional well being. I am open to this but it is not what I hoped when I started out. I agree it is difficult to judge success but those statistics I mentioned coupled with my experience lead me to believe we are handing out way too much pathology. I see loads of people on hospital consults who are on psychiatric disability. They get checks every month for reasons that seem completely unclear to me. Many are not in any psychiatric Tx and use the money for street drugs, booze or prostitution. I think we must judge any social body by what it offers to society and what I am observing does not make me happy about what psychiatry as a collective body is adding to the mix. Regards, John

Regarding buprenorphine, DrJohn wrote: "the success I see with this Tx is nothing short of amazing."

Buprenorphine is replacement therapy. It lets a person manage his/her affairs but it does NOTHING to address the roots of the addiction.

As DrJohn also wrote: "...after 9-12 months when it becomes time to slowly taper them many do not like how they feel.... They just wish to remain on the medication for subjective emotional well being."

Thus, buprenorphine is an example, par excellence, of the anti-psychiatrists' complaint that all we do is "make people dependent on meds." It is a racket, pure and simple.

The problem is that people CAN withdraw from SSRIs or mood stabilizers with only minimal (or no) discomfort. Withdrawal from buprenorphine, on the other hand, is painful, agonizing, and often leads right back to opioid addiction. Keeping someone on buprenorphine simply enriches the manufacturer (and prescribing doc) but morally bankrupts the patient.

BTW, I work in an addiction treatment center, too, and have seen countless examples of ignorant docs handing out scripts for buprenorphine (even with PRN doses!!!!!) with NO expectation for a patient to engage in therapy, 12-step work, or other lifestyle changes.

As of today, I have more people coming in to my treatment center to get off buprenorphine than to get off benzos. What are we doing to people???

Dr. John: I think we're getting off topic, but I want to continue this discussion. Would you be willing (able) to move to Facebook? (This will be my first time to try this, but it seems like a good idea.) I pasted your last comment in the "Discussions" tab and responded. Please counter. Hope this is OK.

pj1280: Probably not as good a stream of income as your rehab facility. And I don't "send" my patients. They decide what treatment they want. Most of them have seen more than one rehab failures. They also know where to find heroin and other agonists.

And BTW: Because of DEA's refusal to schedule audits and the other nuisances associated with buprenorphine maintenance I have stopped accepting new patients and have turned away more than 30 so far.

The Suboxone thread is interesting but off-topic. Coincidentally, the May issue of the Carlat Psychiatry Report will carry a long article on Suboxone. Anyway, please bring that conversation to a different venue. Thanks, your humble moderator.

All of us should appreciate the knowledge and perspective that our training has provided us but we should also acknowledge that we may not fully appreciate the value of other types of training. I am not proposing a relativistic perspective. I am simply saying that there is so much to know in mental health that neither psychiatry nor psychology should lay claim to primacy.

The push for psychologists to pursue medication isn't the only way in which human experience is being externalized. Psychotherapy is increasingly being put forth as a set of interventions geared toward symptom reduction. It isn't just insurance that's pushing all of us to provide simpler answers and briefer treatments. It's also a consumer culture that does not always value or have the patience for process.

Dr. Carlat's call for integration between psychology and psychiatry does not appear to be an attempt to minimize the value of either profession but instead seems to suggest that mental health is special in health care. Mental health doesn't exclusively belong to the academic, the kind-hearted, the scientist, nor the physician.

I think most of us deeply value objective knowledge. The role of early attachment in the development of affect regulation and personality deeply informs my understanding of human nature as a psychologist. But that objective knowledge also points to the profound importance of our clients' and patients' subjective experience. I consider myself competent in the cognitive behavioural treatment of mood and anxiety disorders. CBT isn't an intellectual exercise. It's an experiential one in which complex maladaptive emotional-cognitive-behaviour schema are activated with the aim of promoting both habituation and increased accommodation.

Right now, it seems that both psychology and psychiatry believe that they can simply borrow or tack on components from the other mode and call it a day. While many of us value our larger knowledge base and the cultural background of our training, we should also try to remember that that existing culture may limit our ability to see the possibility of something better.

Wish I had been able to join this discussion earlier… As a prescribing psychologist in New Mexico, I’d like to tell you a little about our group, in order to dispel some stereotypes. Thus far, there are only about twenty of us who are currently prescribing, out of several hundred psychologists in the state. Nearly all of us started the training mid-career or later, out of curiosity about the biological aspects of mental illness and a desire to add an important tool to our repertoire, with little expectation that it would “pay off” financially. As a group, psychologists do not expect, as perhaps most physicians do of earning a “stellar” income. The training is time-consuming, the material difficult, and the national exam (the “PEP”) the most difficult test that most of us have ever taken. Not a few had to take it more than once. Given the time, expense, and difficulty, I do not expect psychopharmacology to “take over” clinical psychology as a field.

The current training model, which I wholeheartedly support, requires that the psychopharmacology trainee already be a practicing, licensed, doctoral level psychologist for five years before beginning the program. This requirement insures that the psychologist has already established his identity as a psychologist and his thinking as “psychological,” before taking on the medical model, with its tendency toward reductionistic thinking.

Thus far, we have proven psychiatrist critics wrong in at least some respects. First, some of us have in fact provided care in areas of the state that have no (that’s right zero) psychiatrists. We also have one working at the state psychiatric hospital, which previously did not have adequate coverage.

Second, although it is difficult to get detailed data, we at least know that, after several years in the field, there have been no complaints to the licensing boards about our prescribers (or in Louisiana for that matter) and no known serious adverse events. For the most part, primary care physicians have been extremely supportive of us and seem relieved to be able to refer some of their most difficult, time-consuming, somaticizing patients to us. I believe that whatever medical knowledge we may lack, in comparison to psychiatrists, is offset by our far greater time spent with each patient (both amount and frequency), our reluctance to engage in polypharmacy, especially at the outset of treatment, and the requirement that we confer with the PCP about drug interactions and possible contraindications (with the psychologist opening these topics) before any major change in treatment (i.e., other than dosage adjustment), whereas psychiatrists (or other medical specialists, for that matter) rarely have the time to do this.

Third, of the twenty or so prescribing psychologists, I know of only three who have taken on psychopharmacology as their primary interest. Both of these spent many hundreds of hours in collaboration with a family medicine residency program; two of them became faculty there. The other is a neuropsychologist by training. The rest of us incorporate medication management as adjunctive to our practice and have no interest (or even an aversion) to doing sessions consisting of medication management only.

Fourth, to my knowledge the pharmaceutical companies have taken no interest in us at this point. I look forward to the day that one finally finds me, so that I can show the mug that I received when joining No Free Lunch.org that says “Just say No to Drug Reps.”

As Dr. Pies pointed out, perceiving the patient in psychological vs. medical frameworks is akin to a figure-ground optical illusion; it is virtually impossible to perceive both at the same time. Given the dominance of the medical model in our culture, it is extremely easy to get locked into the medical framework and lose the other.

Dr. Carlat’s suggestion of a joint education project, created jointly by both psychiatry and psychology together might ultimately be necessary, but would be extremely difficult given the dominance of the medical model, even within a medical specialty that lacks measurable biological data. It would be necessary to teach the two types of models explicitly, along with the danger of reductionism.

Speaking of reductionism, I couldn’t help noticing that those posts that mentioned “placebo” tended to use the term in the usual disparaging way (another consequence of the medical model). After struggling with the concept since becoming a prescriber and reading everything about it that I could get my hands on, I have come to the conclusion that the placebo response is nothing to be scoffed at and indeed needs to harnessed in as effective and ethical way as possible. If most of psychopharmacology rests on it, this does not mean it should be dispensed with and that psychotherapy, preferable as it may be in most situations, can somehow incorporate what has been lost. I believe that drug therapy, for better or worse, has become the dominant healing paradigm in the west and especially in the United States. Belief, expectation, suggestion, and cultural conditioning account for a greater degree of the variance in psychiatry than does the chemical itself.

For a fascinating recent review of the placebo, see the recent article in the Lancet, Volume 375, February 20, 2010, entitled, “Biological, clinical, and ethical advances of placebo effects.” In it, you’ll find persuasive evidence that some analgesic medications work better than placebo, but only when the patient is consciously aware that they are getting it (as opposed to getting it unbeknownst via I.V.). This implies that the medication may be enhancing the placebo effect, rather than the other way around!

It’s an interesting and disturbing conundrum, because for the field to become totally honest about the evidence that placebo is the greater part of what we do would risk undermining the public’s confidence in our work, which would thereby reduce the placebo efficacy.

Dr. Carlat-I am sad to see your comments and wish you could see how NP's/psychologists handle psych patients with no training. I have dealt with some really life threatening cases in psychiatry and would like to pose to those thinking you don't need the medical model to do some consult rotations in the hospital for a week. ICU cases, DKA, pregnant teenagers with HIV are all things you need a medical background to understand! Ask the psychologists what their gonna do when a blood sugar is 600 when they prescribe Zyprexa let alone give proper education to patients and /or caregive information to warn them about DKA. How about neutropenia on clozaril that develops 5 years down the road. The drug interactions that can cause this are endless. Just some examples of many I could go into. This is a disgrace. The meds used in psychiatry are complex and not benign! That is the problem with all of this. Psychiatrists I know would love to do more therapy but the system financially and the way it is set up for them to do so is broken and only going to get worse now that we think we can give others who are less trained to handle psych cases the ability. So now we will have NP's referring to specialist when its unnecessary. Ask some specialists and I am sure they will tell you. BTW-check out www.sermo.com and you will see all the posts from doctors complaining about NP care. Good luck to the patients is all I can say and sorry to hear you support this.

I would just like to point out to a couple of the commentors (and to be fair, I only read about 2/3s of them) that those people who are doing the bulk of therapy (the psychologists and social workers) are not doing psychoanalysis for the very good reason that it has largely been discredited. Cognitive-behavioral therapy, family therapy, etc have taken it's place not because of these people are idiots, but because these methods have greater research support.

That said, I am leaving psychology to go to medical school (although I may not become a psychiatrist) because I am saddened by the disjointed state of the field. Medication / knowledge of neuroscience can be very helpful in treating mental health problems. So can in-depth training in therapy, assessment, and research methods. Social and biological aren't mutally exclusive. In fact, I think we separate them at our peril.

There's also Wright State University in Ohio. I am very fortunate to be a graduate of their program. Residents there spend three years seeing long-term psychotherapy patients in an outpatient clinic dedicated solely to therapy in addition to the normal requirements of residency training. Of course, their department chair, Dr. Jerry Kay, is an analyst and highly encouraged us to engage in our own psychotherapy as well.

The truth is this, prescribing medications is dangerous business... but so is doing psychotherapy. You can seriously damage patients if you are a bad therapist. If psychologists could be adequately trained to safely prescribe, I'm all for it. I would want to see evidence that they can be educated and safe first. I question who is behind this push though... I have yet to meet a psychologist who openly stated they wanted RX privileges. Most seem appalled at the idea. Who wants that type of liability? I have a sneaky suspicion that big Pharma has their hand in this, and that is scary.

Ah yes, long term psychotherapy. I've always wondered what a psychoanalyst does if the patient has the audacity to get better in only a few months! What do they talk about for the next 5 years? "You must agree zat you vill not get betta for at least 4 yeahs or I vill not treat you!"

I know! As a psychiatrist I have one patient who I have seen for medication management and twice weekly psychotherapy (60 min sessions) for nearly 6 years. She is minimally improved, but hasn't attempted suicide again, which in and of itself is a "success" for her. I don't know too many psychiatrists who still do this type of work.

Dr. Carlat,Any advice for a young man planning on going to med school to become a psychiatrist, even though he agrees with much of your critique and fears both missing out on critical psychology training, and having a hell of a battle down the road struggling to provide integrated treatment? thanks.T.

I'm sorry to have come so late to this discussion. I must first say that I thoroughly enjoy your website. From my point of view, the issue is how much time is spent with the patient. When psychiatry frames its job as prescribing medications, then other aspects of the patient's life fade into the background. This often has tragic consequences. Also, I've noticed that some psychiatrists have adopted a cold, clinical approach to patients, and are less warm and empathic than a trusted FP, internist, or rheumatologist. I also think there is a degree of abdication of responsibility when one frames themselves as a 'drug prescriber.' Some of my patients have complained to me that their psychiatrist has told them to call their therapist when they have an emergency, because "I just prescribe your meds." Of course, everyone wants their job to be easier. Why would a psychiatrist want to do both therapy and write scripts? Its easier and more profitable to manage meds. Is it really any different from a neurologist ordering a head MRI for every headache patient?

Also, at the suggestion of a family member who is a psychiatrist, I read Edwin Shorter's 'A Brief History of Psychiatry." I felt quite sorry for psychiatry as a profession. You've had to abandon some of the basic assumptions of your field--psychoanalysic theory--without ever actually testing it empirically. I feel bad that there has been such a sense of discontinuity in psychiatry.